Landscape of organ donation and transplantation activity in Canada Jagbir Gill MD MPH FRCPC Associate Professor of Medicine, UBC Vice President, CORR Board 2017 CST Fellows Symposium, September 25, 2017 Canadian Institute for Health Information September 25, 2017 cihi.ca @cihi_icis
Overview Delivery of donation and transplantation services in Canada Wait-list statistics Organ donation Transplant activity Outcomes
Provincial delivery of OD and T related care 25 adult and pediatric programs perform transplantation 10 Organ donation organizations
Source: Organ Donation and Transplantation Services Report, CBS 2016
Waiting List Statistics 5
Number of Wait-Listed Transplant Candidates by Organ Type, 2007 2016, Canada (preliminary) 4000 3500 3000 2500 2000 1500 1000 500 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Kidney Kidney-Pancreas Liver Heart Lung Note: Excludes Quebec because of under-reporting between 2011 and 2016 6
Number of Kidney Transplant Candidates and Death Rates on the Waiting List, 2007 2016 (preliminary) 3,000 50% 45% 2,500 40% 2,000 35% 30% 1,500 25% 20% 1,000 15% 500 10% 5% 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Kidney 2,159 2,026 1,981 2,399 2,431 2,505 2,629 2,665 2,766 2,840 Deaths 2% 2% 2% 3% 2% 2% 3% 2% 2% 3% 0% Note: Excludes Quebec because of under-reporting between 2011 and 2016 7
Duration of Dialysis prior to first kidney transplant, Adults (18+) by Blood type, 2014 to 2016 (preliminary) Type A Type AB Type B Type O Total Duration on Dialysis (Median Days), Deceased Donor Duration on Dialysis (Median Days), Deceased Donor, No Pre- Emptive Duration on Dialysis (Median Days), Living Donor Duration on Dialysis (Median Days), Living Donor, No Pre- Emptive Note: Excludes Quebec because of under-reporting between 2011 and 2016 1,093 842 1,943 1,739 1,448 1,112 961 1,967 1,744 1,468 269 380 341 297 300 525 548 642 553 551 8
Duration of Dialysis Prior to First Kidney Transplant, Adults (18+), by Province, 2014 to 2016 (preliminary) B.C. Alta. Sask. Man. Ont. N.S. Canada Duration on Dialysis (Median Days), Deceased Donor Duration on Dialysis (Median Days), Deceased Donor, No Pre- Emptive Duration on Dialysis (Median Days), Living Donor Duration on Dialysis (Median Days), Living Donor, No Pre- Emptive Note: Excludes Quebec because of under-reporting between 2011 and 2016 1,420 1,281 1,851 2,114 1,476 1,089 1,448 1,430 1,396 1,883 2,114 1,497 1,231 1,469 202 331 621 562 273 490 297 576 611 828 775 495 636 544 9
Number of Liver Transplant Candidates and Death Rates on the Waiting List, 2007 2016, Canada (preliminary) 600 500 400 300 200 100 30.0 25.0 20.0 15.0 10.0 5.0 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Liver 512 464 431 397 402 374 395 399 382 329 Death Rate 12.7 16.6 17.6 14.9 19.2 11.5 20.0 26.1 15.4 23.7 0.0 Note: Excludes Quebec because of under-reporting between 2011 and 2016
Donor Activity 11
Number of Canadian Organ Donors by Donor Source, 2007 2016, Canada (preliminary) 800 700 600 500 400 300 200 100 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Living 554 546 516 557 521 538 585 553 563 544 Deceased 485 481 487 466 515 541 553 591 649 758 12
Rate per million population Deceased Donor Rate (PMP) by Year, 2007 2016, Canada (preliminary) 25.0 20.0 15.0 10.0 14.7 14.5 14.5 13.7 15.0 15.6 15.7 16.6 18.1 21.1 5.0 0.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 13
Deceased Donor Rate (PMP) by country Source: Organ Donation and Transplantation Services Report, CBS 2016 14
Rate per million population Deceased Donor Rate (PMP) by Region, 2007 2016, Canada (preliminary) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 BC/YK 8.8 12.3 7.2 10.9 12.3 15.3 14.5 14.8 20.1 20.5 AB/NT/NU 13.5 11.3 10.5 8.7 10.2 9.9 11.8 13.7 12.5 16.5 MB/SK 13.2 12.2 12.0 14.5 9.6 7.7 7.2 6.2 10.7 11.9 ON 15.5 13.7 16.8 15.2 16.5 18.8 16.6 19.3 19.4 25.5 QC 18.2 19.5 17.6 15.0 17.1 14.8 20.2 18.7 20.8 20.6 Atl. 13.8 13.7 14.1 13.6 17.7 17.7 13.1 13.5 15.2 16.9 15
Proportion of deceased donors, by age, 2007-2016, Canada 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 1 2 3 4 5 6 7 8 9 10 60+ 55-59 50-54 40-49 18-39 0-17 Note: Excludes Quebec because of under-reporting between 2011 and 2016 16
Proportion of DCD among all deceased donors, 2007-2016, Canada 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 NDD 471 446 444 423 446 456 486 473 514 585 DCD 22 40 43 45 67 86 66 125 138 173. 17
Rate per million population Donor Rate (PMP) by Donor Source (Deceased vs. Living), 2007 2016, Canada (preliminary) 22.0 20.0 18.0 16.0 14.0 12.0 10.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Deceased Donor 14.7 14.5 14.5 13.7 15.0 15.6 15.7 16.6 18.1 21.1 Living Donor 16.8 16.4 15.3 16.4 15.2 15.5 16.6 15.6 15.7 15.2 18
Living Donor Rate (PMP), by country Source: Organ Donation and Transplantation Services Report, CBS 2016 19
Rate per million population Living Donor Rate (PMP) by Region, 2007 2016, Canada (preliminary) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 BC/YT 25.9 18.5 20.5 23.1 23.2 19.7 28.1 22.9 23.7 20.1 AB/NT/NU 20.8 17.3 14.2 21.7 17.5 20.1 20.7 16.6 18.6 20.3 MB/SK 13.2 15.8 9.8 10.1 9.6 13.3 11.8 13.7 7.4 13.6 ON 20.7 21.3 21.2 20.1 19.1 19.0 19.0 20.3 20.3 18.6 QC 6.0 7.0 5.2 6.9 6.0 6.6 6.4 5.7 6.7 6.8 Atl. 12.5 16.7 14.1 12.3 11.0 12.6 13.9 8.4 8.0 7.6 20
Proportion of living donors by relation, 2007-2016, Canada 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 1 2 3 4 5 6 7 8 9 10 Unrelated Spouse Other related Offspring Sibling Parent Note: Excludes Quebec because of under-reporting between 2011 and 2016 22
Transplant Activity 24
Number of Organ Transplants by Donor Source, 2007 2016, Canada (preliminary) 2500 2000 1500 1000 500 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Deceased 1588 1530 1577 1559 1609 1698 1778 1805 1955 2291 Living 554 546 516 557 522 537 585 553 563 544 25
Transplant Rate (PMP), by organ Source: Organ Donation and Transplantation Services Report, CBS 2016 26
Number of Kidney Transplants by Donor Type, Adult (18+), 2006 to 2017 (preliminary) 1,000 900 800 700 600 500 400 300 200 100 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Deceased 523 496 524 553 552 635 563 642 708 885 Living 414 406 402 415 395 391 441 401 411 395 Note: Excludes Quebec because of under-reporting between 2011 and 2016 27
Number of kidney transplants Number of Kidney Transplants by Centre, All Ages, 2016 (preliminary) 200 180 160 140 120 100 80 60 40 20 0 A B C D E F G H I J K L M N O P Q R Number of transplants 2 4 7 7 10 14 25 50 73 78 86 112 115 115 137 144 156 190 Note: Excludes Quebec because of under-reporting between 2011 and 2016 28
Proportion of Kidney Transplants from Deceased vs. Living Donors, by Centre, All Ages, 2016 (preliminary) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% A B C D E F G H I J K L M N O P Q R Living donor 0 2 4 0 5 6 8 21 33 18 31 31 28 48 25 62 38 57 Deceased donor 2 2 3 7 5 8 17 29 40 60 55 81 87 67 112 82 118 133 Note: Excludes Quebec because of under-reporting between 2011 and 2016 29
Kidney Transplant Rate (PMP), 2015, by country Source: Organ Donation and Transplantation Services Report, CBS 2016 30
Liver Transplant Rate (PMP), 2015, by country Source: Organ Donation and Transplantation Services Report, CBS 2016 31
Heart Transplant Rate (PMP), 2015, by country Source: Organ Donation and Transplantation Services Report, CBS 2016 32
Lung Transplant Rates (PMP), 2015, by country Source: Organ Donation and Transplantation Services Report, CBS 2016 33
Outcomes 34
Unadjusted 3-month, 1-, 3- and 5-Year Graft Survival in Kidney Transplant Patients, All ages, by Donor type, Canada, 2007 to 2016 Donor type Living Deceased Time Point 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 N 392 384 384 390 382 367 427 386 398 379 At start 100.0 100.0 99.7 99.7 99.7 100.0 99.8 100.0 100.0 100.0 3 Months 98.7 98.2 99.0 97.7 98.4 98.9 99.1 99.5 99.0 98.0 1 Year 96.4 96.9 97.9 95.6 97.6 98.1 97.2 98.4 97.2. 3 Years 92.6 93.7 95.0 93.3 94.5 94.8 93.0... 5 Years 88.0 89.0 90.6 89.0 89.8..... N 482 460 505 520 526 592 523 596 624 818 At start 99.8 99.8 100.0 99.8 99.6 100.0 99.2 100.0 99.8 99.8 3 Months 96.7 96.5 96.2 98.3 97.1 97.3 96.0 95.3 97.3 96.9 1 Year 93.2 92.8 92.9 95.4 93.2 94.6 93.9 92.6 94.2. 3 Years 86.5 86.5 88.1 91.1 88.2 88.3 89.3... 5 Years 79.9 81.5 81.6 83.4 82.5..... Note: Excludes Quebec because of under-reporting between 2011 and 2016 35
Unadjusted 1-, 5-Year Graft Survival in Kidney Transplant Patients, All ages, by Donor type and Centre (blinded), Canada, 2007 to 2016 Centre A B C D E F G H I J K L M N O P Q R Total N 20 25 34 59 72 162 190 390 475 718 723 730 766 785 842 1,00 2 1,15 2 1,39 0 Living 1 Year Survival 5 Year Survival 80.0 100. 0 80.0 100. 0 100. 0. 97.6 94.3 96.1 97.2 96.3 97.7 97.1 94.6 99.3 96.5 95.1 98.9 98.4 97.1 91.7. 90.8 88.6 93.7 90.5 91.4 90.6 93.6 85.8 95.4 87.6 86.1 87.3 90.6 88.6 Deceased 1 Year Survival 5 Year Survival 93.3 93.3 100. 0 94.5 93.3 91.5 97.4 91.9 95.3 92.6 93.1 94.3 96.9 94.6 93.8 92.2 91.6 93.8 93.3 84.8 90.9 81.8 73.8 75.7 82.4 77.1 80.7 79.0 80.3 83.5 86.2 84.4 83.4 81.7 80.7 83.1 Note: Excludes Quebec because of under-reporting between 2011 and 2016 36
Kidney Transplant Survival, by country Source: Organ Donation and Transplantation Services Report, CBS 2016 37
Percent Unadjusted Three-Month and One-, Three- and Five-Year Patient Survival Rates for Deceased-Donor Liver Transplant Recipients, First Graft, 2007 to 2016, Canada 100 95 90 85 80 75 70 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 3 months 97.4 97.9 94.5 96.6 94.2 96.1 94.7 96.9 94.4 97.5 1 year 92.8 93.7 91.9 92.8 91.1 93.7 90.1 91.8 90.2 3 years 87.4 89.9 85 88.2 85.5 90.2 86.3 5 years 82.7 87.3 81.5 82.4 83 Note: Excludes Quebec because of under-reporting between 2011 and 2016
Summary The number of wait-listed patients outnumber the number transplant recipients Significant rise in deceased donation in Canada in recent years increased transplantation rates in Canada Living donor (kidney) transplantation is declining despite new initiatives Canadian rates of donation and transplantation are lower than the US, but outcomes are better Regional variability in deceased and living donor transplantation indicate room for growth 39
Areas in Development National collaboration and oversight Ongoing need for more granular and standardized provincial and national data Minimizing regional variability in practice Innovation in policy and research to expand access to and outcomes after transplantation 40